Tuesday, April 14, 2009

How important is it to diagnose the specific cause of a patient’s chest pain

---after they have ruled out for MI, PE and aortic dissection? Coders always want us to diagnose a specific cause. “Chest pain due to gastroesophageal reflux disease” pays more than “chest pain cause undetermined”, we’re told.

J. Willis Hurst, Professor of Medicine at Emory, once said that to tell patients what they don’t have without giving them a specific diagnosis is a crotchet:

Some physicians believe they have solved their patients’ problems by stating what the patients do not have. This is a crotchet. I recognize that it is not always possible to state the exact cause of a patient’s chest pain. Despite this, the goal should be to learn as much as possible about the causes of chest pain and not to be satisfied with stating what a patient does not have.

I wonder if this is the right approach. If you’re a hospitalist discharging a patient, once you’ve ruled out ACS, PE, dissection, pneumothorax and pneumonia is it realistic to think you can make a specific and accurate diagnosis? Patients with obvious musculoskeletal pain get sent home from the ER. Cases which get admitted are usually less clear. Once all the serious conditions are ruled out the clinician is under pressure to come up a diagnosis. The coders don’t want to see “chest pain cause undetermined.” The patient and family, eager to “get to the bottom” of what’s wrong, may be resentful or disappointed if you say “we don’t know what was wrong.”

Under such pressure the clinician often resorts to the default diagnosis of ”gastroesophageal reflux disease.” Most patients with non cardiac chest pain do not have GERD, so the “diagnosis” at discharge is mere guesswork. (Try convincing administration or an insurance company to let you keep a stable patient in the hospital for endoscopy or radiographic studies). So the diagnosis of GERD at discharge in patients who “rule out” for cardiac disease is a wastebasket.

This has significant unintended consequences. What happens when you label patients with “GERD”? You are declaring that they are at risk for adenocarcinoma of the esophagus and may need future endoscopic surveillance. Moreover, you, explicitly or implicitly, are committing them to long term treatment, often with a proton pump inhibitor, a regimen not without adverseeffects.

When we discharge patients with unexplained chest pain we are under pressure to pull a diagnosis out of thin air. Sometimes it’s more intellectually honest and better for patients to simply recognize that they often have unexplained symptoms.